Community Resource Database Service Profile
May-14
This profile is used to record information about each program or servicethat your organization offers. Please complete one form for each service.Please complete and email to or fax to 321-631-9291.
Name of Program: Enter program name here
Service sites/locations (list the sites or locations where these services are offered, referencing the Site Profile names/numbers. For example, “Elm Street Center, Site 1”)
1.Enter site name/number / 4.Enter site name/number2.Enter site name/number / 5.Enter site name/number
3.Enter site name/number / 6.Enter site name/number
Description of Service:
Click here to enter text.
Service Days/Hours:
☐ Monday from / Enter start time to / Enter end time / ☐ Friday from / Enter start time to / Enter end time /☐ Tuesday from / Enter start time to / Enter end time / ☐ Saturday from / Enter start time to / Enter end time /
☐ Wednesday from / Enter start time to / Enter end time / ☐ Monday from / Enter start time to / Enter end time /
☐ Thursday from / Enter start time to / Enter end time /
Eligibility Requirements:
Gender: ☐Male☐Female
Age:☐ All OR: MinimumMinimim age. Maximum Maximum age.
Income: e.g., “100% of poverty level”, “none” .Other: Click here to enter additional info.
Intake Procedures:☐ Appointment required☐ Telephone for service☐ Appointment preferred ☐ Telephone to apply ☐ Call or walk in to apply ☐ Write for service
☐ Call or walk in for service☐ Walk in for service
☐ Additional Info: Click here to enter text.
Fees:☐ Free☐ Sliding Scale☐ Donations Requested
☐ Membership Fee☐ Fixed Fee
☐ Other:Enter other fee info here.
Payments Accepted:☐ Cash☐ Check☐ Credit Card
☐ Medicare☐ Money Order☐ Private/Military Insurance
☐ Other: Enter other forms of payment.
Documents Required: ☐ FLDL☐ SS Card☐ Proof of Residence☐ Other Enter other required documentation.
Do you provide interpreters for non-English speakers? ☐ Yes ☐ No
If yes,languages: Click here to enter languages. ☐ Staff ☐ Interpreters
Area Served:(Please list by specific zip codes, city, or other boundaries if geographic eligibility is limited)
e.g., “Melbourne”, “South of Elm Street, East of Oak Street, West of Pecan Lane, North of Hickory Rd.”.
We meet all the Federal, State and Local laws, requirements and regulations including fire, health and zoning codes. ☐ Yes ☐ No If no, please explain: Please explain exceptions.
☐To the best of my knowledge all of the preceding information is true and correct.
Person Completing Form: Click here to enter text.Phone:Click here to enter text.
Email:Click here to enter text.Date:Click here to enter a date.
Complete service classification info on following page
Service Category
Basic Needs
☐ Food (Please describe – e.g., food pantry, home delivered meals, etc.) Click here to enter text.
☐ Utility Assistance : ☐ Electric ☐ Gas ☐ Water ☐ Deposits
☐ Housing/Shelter (please describe – e.g. emergency, transitional, etc.) Click here to enter text.
☐ Housing Expense Assistance: ☐ Rent ☐ Mortgage ☐ Deposits
☐ Material Goods (please describe – e.g., clothing, furniture, diapers, etc.) Click here to enter text.
☐ Transportation (please describe)Click here to enter text.
☐ Other, please describe: Click here to enter text.
Consumer Services
☐ Consumer Assistance & Protection ☐ Consumer Regulation ☐ Money Management ☐ Tax Assistance
☐ Other, please describe: Click here to enter text.
Criminal Justice & Legal Services
☐ Courts ☐ Criminal Correctional System ☐ Law Enforcement ☐Legal Services
☐ Other, please describe: Click here to enter text.
Education
☐ Educational Institution/School ☐ Educational Programs ☐Educational Support Services
☐ Other, please describe: Click here to enter text.
Environment & Public Health/Safety
☐ Public Health ☐ Public Safety ☐ Other, please describe: Click here to enter text.
Health Care
☐ Emergency Medical Care ☐ General Medical Care ☐ Other, please describe: Click here to enter text.
Income Support & Employment
☐ Employment Services, please describe: Click here to enter text.
☐ Public Assistance Programs, please describe: Click here to enter text.
☐Social Insurance Program, please describe: Click here to enter text.
☐ Other, please describe: Click here to enter text.
Individual & Family Life
☐ Adoption Services☐ Adult Day Services ☐ Burial Assistance/Death Certification
☐ Caregiver Services☐ Case/Care Management☐ Emergency Alert Services
☐ Parent Education☐ Protective Services☐ Respite Care
☐ Other, please describe: Click here to enter text.
Mental Health & Substance Abuse
☐ Mental Health Services, please describe: Click here to enter text.
☐ Substance Abuse Services, please describe: Click here to enter text.
☐ Other, please describe: Click here to enter text.
Target Populations
☐Please describe: Click here to enter text.
Additional Notes/Information: Click here to enter text.